y 1 ^♦^ 



Backward Children 



IN THE 



Public Schools 



With a Preliminary Study on 

THE RELATION OF PHYSICAL TO MENTAL DEFECTS 
IN SCHOOL CHILDREN 



BY 

WALTER S. CORNELL, M.D. 

PHILADELPHIA. PENNA. 

Dbmonstkator of Osteology, University of Pennsylvania; Physician to the Dispensary 

FOR Nervous Diseases, Presbyterian Hospital; Assistant Medical 

Inspector, Bureau of Health 



irilUBtrateO Mitb malMone plates 



PHILADELPHIA 

F. A. DAVIS COMPANY 

PUBLISHERS 



Price, 25cts., Net, Postpaid 



BACKWARD CHILDREN 



PUBLIC SCHOOLS 



With a Preliminary Study on 

THE RELATION OF PHYSICAL TO MENTAL DEFECTS 
IN SCHOOL CHILDREN 



By WALTER S. CORNELL, M.D. 

PHILADELPHIA, PENNA. 
Demonstrator of Osteology. University of Pennsylvania; Physician to the Dispensary 
FOR Nervous Diseases, Presbyterian Hospital; Assistant Medical 
Inspector, Bureau of Health 




PHILADELPHIA 

F. A. DAVIS COMPANY 

PUBLISHERS 



I 



LC-^for. 



^; 



'|irBKARY of OOMsiElsl 
i Two Copies Ketiiivat! 

MAR t!l 1308 

\ sioj/ycigiii ciUT.v 

(CUSS A m&. Mo. 

COPY 8. 



Copyright 1908 

BY 

F. A. Davis Company 



\'. 



THE RELATION OF PHYSICAL TO MENTAL 
DEFECT IN SCHOOL CHILDREN. 



The age of our race between 6 and 15 years is a 
distinctive one, from the fact that the problem of diet, so 
important in infancy, decreases with the corresponding 
increase in bodily activity. So, also, the prevalence and 
effect of contagious disease suffer a reduction. For these 
reasons the mortality rate decreases progressively, and the 
probability of survival becomes steadily brighter. 

The age of development, however, is one in which the 
subsequent physical and mental welfare is largely prede- 
termined. Though the child's life be fairly safe, his for- 
tune still lies largely in the hands of his parents, his envi- 
ronment, his teacher, and his physician. First must be met 
the burdens of heredity, producing thousands of sickly, 
deformed, and neurotic children. A perpetually (or rather, 
life-long) acting force is here to be combatted and reck- 
oned with. Second to heredity is a poor city environment, 
with its lack of fresh air and its improper diet of canned 
foods. Exposed to these influences healthy infants succumb, 
and join the ranks of those already suffering from rickets, 
anaemia, and adenoid nasal obstruction. Finally, the igno- 
rance of parents causes indifference to the damage already 
done, and adds premature decay of the teeth to the existing 
list of evident physical imperfections. " 

Are these injuries to the health of the child also harm- 
ful to his mind? Will he ultimately pass through their 

(1) 



2 The Medical Inspection of School Children. 

pale of influence more or less scarred, but possessing the 
same knowledge and mental faculty that make for power, 
as his more vigorous neighbor? 

The physical basis of mental defect becomes more and 
more evident as our psychopathic investigations increase 
in accuracy. 

Among the imbecile and idiotic class in children, the 
agencies producing the mental condition, such as cerebral 
haemorrhage and paralysis, or hydrocephalus, are very ap- 
parent to any observer. 

Feeble-minded children, the result of vicious, drunken, 
or imbecilic ancestry, show physical defects less evident to 
gross observation, but demonstrable, nevertheless, by super- 
ficial examination, by autopsy, and by subsequent brain 
examination. 

Backward and subnormal children approach so nearly 
the ordinary child that the connection between physical 
defect and brain defect is often not demonstrable at all in 
individual cases. In these the acting influences are of minor 
degree, being principally poor eyesight, deafness, and poor 
nutrition (adenoid growths are included in the latter two). 
We may either assume that the rule of a sound mind in a 
sound body is a natural law, and so reason by analogy that 
it operates in these cases, or by a study of a large series of 
cases draw positive original conclusions from this very 
class itself. The latter is well worth proving, if it be pos- 
sible to do so. 

That the mentally defective show physical defect is 
overwhelmingly proven by the statistics of asylums and 
training schools, by the writings of Shuttleworth, Barr, and 
Ireland, and by the most superficial observation on the part 
of any one who visits custodial institutions for these cases. 
Juvenile criminals usually show mental and physical de- 



Relation of Physical to Mental Defect. 



feet, as has been shown by MacDonald (Medical Record, 
July 20, 1907). 

Even in the special classes for backward children con- 
ducted by our large cities, the reports show that almost 
every backward child shows physical defect of some sort. 
In these classes the proportion of such children is given by 
one authority as 95 per cent, of the whole number. Dr. 
John J. Cronin, of New York, tells me that of 150 back- 
ward children examined, 81 were actually operated upon 
subsequently for adenoid growths. 

In regard to the backward children in the Boston 
schools, the Massachusetts Health Report (April, 1907) 
states : — 

"Certain facts concerning some of the so-called un- 
graded classes in Boston are significant. These classes are 
composed of children who have failed to keep up with the 
work in the lower grades. They are grouped in small 
classes, and given chiefly individual work. 

"Of 43 girls of this class in one school, but 2 were 
found normal in vision and hearing. 

"Of 66 boys in another school, 64 per cent, were found 
defective in vision ; while the rest of the school, 473 boys, 
36 per cent, were defective. 

"In another school, boys and girls, of 40 children in 
ungraded classes, 65 per cent, were found defective in vision 
or hearing, or both ; while of the remaining 707 children, 
36 per cent, were defective." 

The writer personally visited a special class in New 
York City in which the whole number of children (18) had 
nasal obstruction or catarrh ; 8 were also defective in vision, 
and 3 of the latter suffered from deafness. Numerous other 
defects and malformations were evident. 

That the physically defective among ordinary school- 



4 The Medical Inspection of School Children. 

children show subnormal mentality is the converse of the 
last proposition and should be capable of demonstration. 

In the following investigation I have endeavored to 
clearly establish this relationship. The children studied 
were those of three Philadelphia public schools who had 
previously been physically examined by myself in conjunc- 
tion with the official work of medical school inspection. 

The first step was the recording, in each school, of the 
name, physical record, and scholarship of each child. The 
latter was obtained by using the previous term-marks in 
three of the school studies, from which an average mark 
was easily calculated. 

The average term-mark of the whole school was first 
obtained by the simple process of adding the term-marks 
of all the children together, and dividing by the number 
of children. For instance, in the Claghorn School this was 
73-I- 

Relation of all Physical Defects to 
Scholarship. 

The record-cards of the children were then divided 
into two collections : one of the healthy or normal children, 
the other of the general group showing some noteworthy 
physical defect. The average term-mark (the scholarship 
index) was then calculated for each group separately, and 
the two compared, first with each other, and then with the 
term-mark of all the children previously calculated. 

The results showed that in each school, and in each 
individual branch of study in each school, the healthy or 
normal children stood higher in their classes than the aver- 
age children, and the physical defectives, taken as a class, 
stood lower than the average children. 



Relation of Physical to Mental Defect, 



Allison School — 219 Children, Both Sexes, 6 to 12 Years Old. 

Average 

Normal child 75 

Average child i 74 

General defectives 72.6 

Adenoids and enlarged tonsils 72 

Deaf 67.2 



Ninth Street Primary School — 84 Children, Both Sexes, 
6 to 10 Yeaks Old. 

Language Arithmetic Spelling Average 

63 cases normal children 72.9 75.5 75.4 74.6 

84 cases average child 70.5 74 72.8 72.4 

21 cases general defectives 63.3 70 64.8 66 

8 cases adenoids 60 66.7 65 63.9 

No cases deaf. 

Claghorn School — 252 Children, Both Sexes, 12 to 15 Years Old. 

Geography- 
Language Arithmetic and Average 
History 

179 cases normal children.... 74.4 72 76.6 74.3 

252 cases average child 72.7 70 76.5 73.1 

73 cases general defectives 71.4 65.1 76.2 70.8 



An investigation on slightly different lines was afforded 
by the existence in the Claghorn School of four classes of 
the same grammar grade, which had been so made up at 
the beginning of the year that the brighter children consti- 
tuted two classes, and the duller children the other two 
classes. The latter were smaller, so as to afford more op- 
portunity for individual instruction. A comparison of the 
physical condition of the children is interesting and instruc- 
tive : — 

Class 1 Class 15 Class 9 Class 11 

Dullest 
Bright Children Dull Children Children 

Number of children 50 39 32 29 

Proportion of normal to defective children: — 

Normal 36 32 20 13 

Defective 14 7 12 16 

Percentage of normal 

children, 72% 82% 62.5% 44.8% 



6 The Medical Inspection of School Children. 

In June, 1906, the school medical inspection corps of 
Philadelphia was directed by its chief, Dr. Thomas J. 
Beatty, to make a comparative study of those bright chil- 
dren exempted from their annual examinations, and those 
children whose lower scholastic standard necessitated their 
examination for promotion. The proportion of physical 
defects recorded in the two groups was made the basis of 
comparison. I am indebted to Dr. Beatty for permission to 
publish the figures which I submitted to him at that time. 
It will be observed that, on averaging the five schools, the 
brighter children showed the less percentage of physical 
defect. 

Exempt Children. Non-Exempt Children. 

Normal. Defective. Normal. Defective. 

Ninth St. Primary School . . 56 28 39 38 

Rutledge School 87 35 75 34 

Allison School 128 65 81 49 

Camac School 183 71 103 75 

Claghorn School 193 61 127 66 

647 260 425 262 

Percentage defective, Percentage defective, 
28.8 per cent. 38.1 per cent. 

The Massachusetts Health Report above quoted also 
demonstrates the close relation of physical and mental de- 
fect by an independent investigation. In part it states : — 

"Of 420 children examined, 40 per cent, had perfect 
vision, 30 per cent, had mild defects, and 23 per cent, had 
serious defects. 

"Of scholars ranked as 'excellent,' 50 per cent, had 
normal eyes, and 14 per cent, had serious defects. 

"Of scholars ranked as 'unsatisfactory,' 40 per cent, 
had serious eye defects. 

"Of the 'excellent' scholars, 17 per cent, had dimin- 
ished hearing. 

"Of the 'good' scholars, 20 per cent, had diminished 
hearing. 



Relation of Physical to Mental Defect. 



"Of the 'unsatisfactory' scholars, 52 per cent, had 
diminished hearing. 

"Of the 'poor' scholars, 42 per cent, had diminished 
hearing." 

The standard of normal hearing in these tests was 
evidently placed higher than is usually the custom in routine 
school inspection. 

Relation of Poor Eyesight to Scholarship. 

A separate study was made to show the single influ- 
ence of poor eyesight on the scholarship of the children 
(New York Medical Journal, June i, 1907). The records 
of the Allison School were used. A series list was made 
of 219 children, their visual acuity, and their term-marks 
in arithmetic, geography, and spelling. For convenience 
vision was designated as normal if it exceeded three- 
fourths, fair if it exceeded one-half, and bad if it was one- 
half or less. The children were first grouped according to 
their acuity of vision with the following result: — 

Arithmetic Geography Spelling Average 

Normal vision 79 69 76 75 — 

Fair vision 70 71 77 73-}- 

Bad vision 66 70 71 69 

This difference of six points is often the difference 
between promotion and failure in a child's work. It is in- 
teresting also to note the great difference in the arithmetic 
marking and the slight difference in the geography mark- 
ing, the latter being acquired largely by oral instruction 
rather than blackboard work. 

Relation of Nose and Throat Defects to 
Scholarship. 

An effort was made to determine the exact degree of 
influence of defect of the nose and throat. The harmful 



The Medical Inspection of School Children. 



results of these are well recognized in late years. In the 
Claghorn School the four classes of bright and dull chil- 
dren were examined again. Their eyesight proved to be 
about the same (averaging '-^, ^, ^g', '-f). En- 
larged tonsils, adenoids, deafness, and nasal catarrh oc- 
curred much more frequently, however, among the two 
classes of duller children. In many the adenoid expression 
was written only too plainly on their faces (see illustra- 
tions). The following table shows the findings: — 

Class 1 Class 15 Class 9 Class 11 

Dullest 
Bright Children Dull Children Children 

Number of children 50 .39 32 29 

Nose and throat conditions: — 

Number defective 6 4 9 9 

With single or combined defects, viz.: — 

Tonsils 3 4 3 3 

Adenoids 2 1 5 6 

Deaf 2 — 5 1 

Catarrh — — 2 3 

Percentage of children with nose 

and throat defects 12% 10.2% 28.1% 31% 

The conclusions to be drawn from the foregoing facts 
are very apparent. The educational result in our public 
schools suffers a discount of about 6 per cent, in the case 
of the physically defective children, as well as a waste of 
the time rightfully belonging to the normal children. The 
drain on the teacher's energies is more than proportionately 
increased by the presence of such children, because of their 
associated nervousness or stupidity. 

To remedy these conditions, educators turn to the med- 
ical profession as their only source of relief, and the trusted 
family physician is largely responsible for the condition of 
affairs which exists, whether good or evil. In many cases 
he not only guards the health of his charges, but by his 
alertness or indifference determines their intellectual growth, 
their scholastic career, and their subsequent life's work. 




New York school boy, before and after removal of adenoid growths 
from the naso-pharynx. 



Relation of Physical to Mental Defect. 



In this connection it is well to note that a laborious statistical 
study of the relation of nutrition to scholarship showed practically nega- 
tive results. This investigation was made by Mr. Albert E. Dudley, 
principal of the Claghorn Grammar School, Philadelphia, in collabora- 
tion with the author. Three hundred and fifty-eight boys, whose ages 
ranged from nine to sixteen years, were weighed and classified in three 
groups. The middle group (class B) comprised those boys whose weight 
per age corresponded to the standard figures of the Metropolitan Life 
Insurance Company, or within one year's variation of the same. The 
boys of heavier weight per age constituted class A, and the boys of less 
weight per age (supposed to be poor nutrition cases) constituted class 
C. The same procedure was followed in the case of the girls. The 
scholastic standing of the individual in each group was then obtained 
and averaged, so that the groups could be compared. The results fol- 
low:— 

Boys (358). School term Average. 

Class A, heavy weight for age ( 120 boys) 71.6 

Class B, medium weight for age ( 168 boys) 71.2 

Class C, light weight for age (70 boys) 72. 

Girls (225). 

■ Class A, hea^'y weight for age (97 girls) 73.7 

Class B, medium weight for age (100 girls) 72.1 

Class C, light weight for age (28 girls) 70.6 

Since an accurate estimate of nutrition can be made only by taking 
the height as well as the age into account, the omission of the former 
procedure may possibly have introduced a factor of error in the above 
conclusion. For this reason it is our intention to revise this paper. 
There is no doubt, however, that numerous individual cases exist in 
which anaemia and poor nutrition not only retard school progress, but 
prevent it altogether. 



BACKWARD CHILDREN IN THE PUBLIC 
SCHOOLS* 



The subject of mentally deficient school children is 
at the present time attracting the interest of educators to 
an extraordinary degree, and very naturally so, since the 
institution of classes for the special instruction of such 
backward children acts both as a benefit to them, and as 
an educational economy to the regular-grade teacher and 
to the great mass of normal children. Consideration of 
this aspect of special education, which may be called the 
pedagogical aspect, is given in the general chapter bearing 
on administration. In this connection the medical and 
psychological features will be considered. 

Those who are especially interested in mental defec- 
tives should not content themselves with a mere book pre- 
sentation of this subject. A clear, confident comprehension 
of it can be best obtained by actual observation of defective 
children in such institutions as the New Jersey Training 
School at Vineland, the Massachusetts School for the 
Feeble-minded at Waverly, the Pennsylvania Training 
School at Elwyn, and the special public school classes for 
backward children in New York City, London, and Berlin, 

I. CLASSIFICATION 

Children with mentality below the average may be 
divided into two great classes. 

The first group consists of those children who are 
(10) 



Backward Children. 11 



but slightly below the normal standard. Their mind proc- 
esses are sluggish, or of slower growth than normal, or 
perhaps they are peculiar emotionally or lacking in gen- 
eral nervous tone. These children are often termed back- 
ward, or "atypical," or "exceptional." 

Backward children, such as may be found in the public 
schools, may be again classified into two groups. They are 
truly backzvard when the chief defect is in the brain itself, 
and apparently backzvard (or pseudo-backward) when de- 
fect of some other part of the body, or the child's home 
environment, is the cause. The causes producing apparent 
backwardness are largely removable by proper medical care 
and by improvement in the child's surroundings; and this 
would lead us to hope that a child placed in a good home, 
and perhaps fitted with proper eye-glasses or cured of deaf- 
ness, is enabled thereby to resume his normal mental devel- 
opment, and cease to be a backward child. This is usually 
the case, but unfortunately not always so. A youthful 
brain arrested too long in its development suffers the same 
blighting effects as do the bound feet of the Chinese woman 
or the distorted, suppressed vision of a child's squinting 
eye. The brain may ultimately be given its opportunity, 
the bandage may ultimately be removed from the feet, and 
the crossed eye be made straight by operation, but lack of 
early exercise results in each case in permanent functional 
weakness. 

Therefore a child originally apparently backward may 
become truly backward from lack of the brain exercise nec- 
essary to brain development. 

The second group includes all these children below 
those of the first group, and generally termed "feeble- 
minded." They range from the highest grade of such 
children (classified as feeble-minded in its restricted sense) 



12 The Medical Inspection of School Children. 

through the various grades of imbecihty down to idiocy. 
In them there is some inherent brain defect precluding the 
possibiHty of their attaining normal mentality, and often 
lirniting their possibility of improvement. Their defect is 
usually evident to any one. They require institution care 
and training, and are not properly considered here. 

II. THE CAUSES OF BACKWARDNESS. 

Children of such mental development that their parents 
consider them capable of entering the public schools are 
usually normal, sometimes backward, and rarely actually 
feeble-minded. Occasionally feeble-minded and imbecile 
children creep in and lodge for a while. The minor grade 
cases, which make up the majority of public school defec- 
tives, are logically caused by the minor grade physical 
defects, such as deafness, malnutrition, adenoids, and poor 
eyesight. Gross deformities and diseases of the brain are 
more likely to produce imbecility or even idiocy, and con- 
demn their possessors to asylums or training institutions. 

The relation of physical to mental defect has been 
already discussed in the chapter devoted to that subject, and 
the demonstration made that normal children always attain 
higher school averages than physically defective ones, and 
further that the individual factors of poor eyesight, ade- 
noids, deafness, and poor nutrition have each been shown 
to lower the scholastic average. The physical signs, as well 
as the child's words and actions, are therefore the criterion 
by which mental defect is diagnosed. 

In the lower social strata, among the poor and igno- 
rant, the active causes producing backward school children 
are frequently environmental, including evil home sur- 
roundings, poor nourishment, and the inherited taints of 
syphilis and alcohol. 



Backward Children. 13 



A systematic classification of the causes of backward- 
ness may be made as follows : — 

A. True Backwardness. 

1. An inherent functional weakness of the brain and nerv- 

ous system. This is often hereditary. It may be 
due to injury or illness of the mother previous to 
the birth of the child, to poverty, or to parental dis- 
sipation. 

2. Serious defects of the special senses. This is especially 

true of deafness, for blind children are saved in this 
respect because of their early institutional training. 
Defects of the external sense organs prevent the ex- 
ercise and development of their corresponding brain 
centres. 

3. Any of the physical causes of feeble-mindedness, but 

acting to a less degree. This is but simple mention 
of numerous accidents, diseases, and deformities enu- 
merated in detail in the chapter devoted to that sub- 
ject. They consist mainly in organic defects and 
lesions of the brain. 

B. Apparent or Pseudo-backwardness. 

1. Children with slower rate of mental development, or un- 

even rate of development. These children may sub- 
sequently show great ability. It is said that Haw- 
thorne, Sir Walter Scott, Napoleon, Clive, Welling- 
• ton, Froebel, Linnaeus, Webster, Chatterton, Leigh 
Hunt, and Sir Isaac Newton were dull boys at school. 

2. Lesser defects of eyesight and hearing. 

3. Poor nourishment, anaemia, and physical weakness. This 

may be due to poverty, or to yery rapid growth, or 
to illness, such as scarlet fever, or to Bright's disease. 



14 The Medical Inspection of School Children. 



4. Adenoid growths. These act by producing deafness 

and poor nutrition, and possibly by inducing a slug- 
gish circulation at the base of the brain. 

5. Troublesome, spoiled, unhappy, and neglected children. 

This classification is partly based on the admirable one of Dr. 
M. P. Groszmann, of Plainfield, New Jersey. 

III. THE SYMPTOMS AND DIAGNOSIS OF 
BACKWARDNESS. 

The preliminary diagnosis is made by the teacher. The final 
official diagnosis should be made by the medical inspector or consulting 
physician. 

A. Teacher's Preliminary Diagnosis. 

A very helpful knowledge of the diagnostic signs of 
mental incompetency may be obtained from a book descrip- 
tion, and certainly enough may be obtained for an intelli- 
gent teacher to tentatively select such cases in her class 
and set them aside for expert examination. A thorough 
and practical knowledge, which gives the power of confi- 
dent and accurate diagnosis, is only acquired, however, by 
actual contact with numbers of such children in classes or 
institutions. The latter, containing feeble-minded children 
of all degrees, whose physical and nervous defects are pro- 
nounced enough to admit of study and comparison, fur- 
nish practical instruction in diagnosis that cannot be ob- 
tained elsewhere. 

The student or teacher who derives his knowledge 
solely from text-books is apt to assume that their classifi- 
cations of mental deficiency are exactly illustrated in life 
by the subjects, whereas such classifications are entirely 
artificial and devised simply for the sake of convenience. 
In a graded series, the mentality of the lowest member of 
one group is exactly that of the highest member in the 




Case of nasal obstruction from adenoids, showing 

characteristic dull facial expression. 

(Courtesy of Dr. B. C. Gile.) 




Group of New York school children who had previously suffered 
from adenoid growths. These children were operated upon and sent to 
the country for two weeks, and are now returning improved in health. The 
cases marked with a cross + also show, when smiling, the broad bridge of 
the nose and sunken vacant mouth often resulting from adenoids. 

(Courtesy of Dr. Thomas Darlington and Dr. John J. Cronin. ) 



Backward Children. 15 



group below. The complexity of the various manifesta- 
tions of the mind, such as the emotions and intellect, and 
of the moral sense make even an exact gradation impossible. 

Text-book statements of the physical defects often 
accompanying feeble-mindedness in its various degrees of 
existence are also apt to cause the inexperienced teacher 
to form the hasty conclusion that every mentally defective 
child bears a sort of label or tag, such as adenoids, or pro- 
truding ears, or a peculiarly shaped head, by which obvious 
ph5^sical defect it can be readily distinguished from its fel- 
lows. As a matter of fact, these signs are simply sug- 
gestive and corroborative; and there exist idiot children 
of perfect physical development, as well as extremely bright 
children with all sorts of unfortunate physical characteris- 
tics. The occurrence of these physical defects should sim- 
ply be regarded as ground for suspicion, but nothing more. 

The diagnosis of a poorly developed mind should be 
based entirely on the child's thoughts as expressed by its 
words and actions. 

The grade teacher herself should make the preliminary 
observations and diagnosis of backwardness in a child. The 
evidence, both direct and corroborative, should be carefully 
recorded on an appropriate official card. 

The teacher's diagnosis should rest upon : — 

1. Observation of Obvious Physical Defects, or knowl- 

edge of the existence of such defects from the offi- 
cial physical record. 

2. Observation of Symptoms indicative of nervous dis- 

order. 

3. Observation of Psychic Symptoms indicative of men- 

tal deficiency. 

4. Knowledge of such Mental Defect gained by sys- 

tematic routine testing of the whole number of 
children. 



16 The Medical Inspection of School Children. 

1. Physical Defects Frequently Associated with (and Often 

Causative of) Backwardness: — 

Very poor eyesight, including squint cases. 

Deafness, with or without discharging ears. 

Poor general health. 

Peculiar shape or size of the skull. 

Low forehead, peculiar ears, high palate. 

Vacant facial expression. 

Adenoid growths, causing nasal obstruction. 

2. Disorders and Defects of the General Nervous System: — 

These signs may or may not be indicative of men- 
tal defect. They are suspicious, not conclu- 
sive. 

Lack of strength and vigor, manifested by rapid fa- 
tigue, shambling gait, and slouching position. 

Low or irritable nerve-tone, manifested by uneasiness, 
restlessness, and muscle twitchings, particularly 
of the fingers and jaws. A more severe condi- 
tion is chorea (St. Vitus dance), characterized 
by involuntary rolling of the eyeballs, by spas- 
modic movements of the muscles of the face, 
jaws or neck, or by shuffling of the feet. Some 
cases of epilepsy are the result of a highly irri- 
table nervous system. 

Epileptic convulsions. 

Poor coordination, manifested by inability to thread 
needles, button garments, lace shoes, or perform 
any but the simplest mechanical acts. 

3. Direct Psychic Evidence of Mental Defect by Observa- 

tion : — 

Inability to perform regular school work, designed 
for average pupils of the child's age. 



Backward Children. 17 



Rapid mental fatigue. 

Dullness and listlessness. 

Excitability and emotionalism. 

Stubbornness and bad temper. 

Demonstrative expression of desire. 

Lack of judgment. 

Inattention. 

Untidy or uncleanly personal habits. 

Defective speech. 

4. Knowledge of Mental Defect by Test: — 

Defects of Perception (of color, form, size, num- 
ber). 
Defects of Concept of Number. 
Defects of Memory. 
Defects of Association. 
Defects of Attention. 
Defects of Coordination. 
Defects of Imitation. 

y It is understood, of course, that the following tests are 

elementary in character and do not assume to classify the 
faculties nor to investigate thoroughly those that are 
touched upon. The first is beyond our power, and the 
second too complex for our practical purpose. 

The exact value of psychological tests for the detection 
of mental defect is as yet undetermined. In the first grade, 
containing the )^ounger children, the elementary lessons in 
arithmetic, spelling, and writing are now so scientifically 
formulated as to call directly upon the simplest faculties 
of the mind almost as well as any special tests that can be 
devised. Simple counting of concrete objects, for instance, 
is the test for the perception of number; spelling and the 
recognition of words show the power of memory and the 



18 The Medical Inspection of School Children. 



perception of form. Addition or multiplication of abstract 
numbers is the test of the concept of number. Writing is 
a test of coordination, not to mention motor power. How- 
ever, special tests of the simplest character, such as the 
form board, tests of color and of size, will help much to 
fix the grade of a small child's intellect. 

Among the older children, the complexity of their 
studies makes it difficult for the teacher to accurately per- 
ceive the particularly defective faculties in the child's men- 
tal make-up. For this reason attempts have been made by 
psychologists, with varying degrees of success, to prepare 
\ mind-charts and systematic tests, and thus obtain the accu- 
rate insight desired. 

I am greatly indebted to Dr. Goddard, psychologist 
to the New Jersey Training School for Feeble-minded 
Children, for suggestions and material embodied in the 
test system given below and in the appendix. 

The tests embodying words and letters are abstracted 
and condensed from a thesis on this general subject by 
Dr. Naomi Norsworthy, of Columbia University. 

Test of Color : — 

A. Kindergarten Children : Color sense may be tested 

by the ability to recognize differences of color. 
A pile of blocks or cards, or some yarns of, say, 
three different colors, may be used. It should 
be remembered that a very small number of 
children are born color-blind, and in these cases 
red and green cannot be distinguished. It is 
well, therefore, not to use these colors exclu- 
sively. 

B. Primary Children: Test as for "A." After the 

child demonstrates that he distinguishes differ- 



Backward Children. 



19 



ence of color (color-sense), he may be tested, 
after instruction, for the recognition of simple 
colors (color perception). 

Test of Form Perception : — 

A, Kindergarten Children: The form board is use- 
ful, the test consisting in the placing of the 
blocks in their proper places. The facility with 
which this is done should be noted. A child of 
six to fifteen years will fill a board of ten blocks 
in thirty to fifteen seconds. 




Form Board. 

B. Primary Children : The recognition of some letter 
known to the child, as it may happen to occur 
in a mass of printed matter, is a good test. Thus, 
on a printed or mimeographed slip the children 
may be given an exercise to cross out the letter 
A wherever it may occur, a time limit being ob- 
served. Such a test, already tried and stand- 
ardized by Dr. Norsworthy, is given below. 



20 The Medical Inspection of School Children. 

Table Containing: the Letter A One Hundred Times. As many of 
tliese as possible to be crossed out in one minute. 

OYKFIUDBHTAGDAACDIXAMRPAGQZTAACV 

AOWLYXWABBTHJJANEEFAAMEAACBSVSK 

ALLPHANRNPKAZFYRQAQEAXJUDFOIMWZSA 

UCGVAOABMAYDYAAZJDALJACINEVBGAOFH 

ARPVEJCTQZAPJLEIQWNAHRBUIASSNZMWA 

AAWHACAXHXQAXTDPUTYGSKGRKVLGKIM 

FUOFAAKYFGTMBLYZIJAAVAUAACXDTVDAC 

JSIUFMOTXWAMQEAKHAOPXZWCAIRBRZNSO 

QAQLMDGUSGBAKNAAPLPAAAHYOAEKLNV 

FARJAEHNPWIBAYAQRKUPDSHAAQGGHTAM 

ZAQGMTPNURQNXIJEOWYCREJDUOLJCCAKSZ 

AUAFERFAWAFZAWXBAAAVHAMBATADKVS 

TVNAPLILAOXYSJUOVYIVPAAPSDNLKRQAAO 

JLEGAAQYEMPAZNTIBXGAIMRUSAWZAZWXA 

MXBDXAJZECNABAHGDVSVFTCLAYKUKCWA 

AFRWHTOYAFAAAOH 

GiELs Boys 



A.GE 


Average 

Number of A'a 

Crossed Out 


Normal 
Limit of 
Variation 


Average 

Number of A 6 

Crossed Out 


Normal 
Limit of 
Variation 


9 


32.6 


4.5 


28.4 


2.1 


12 


45.9 


7.3 


41.3 


4.4 


15 


54.1 


7.3 


48.6 


4.4 


16.5 


57.0 


7.3 


51.2 


4.4 



Test of Size Perception : — 

A. Kindergarten Children: Marbles of two or three 

sizes may be used and the child asked to pick 
out the large ones or the small ones. He may 
be asked to make big circles or little circles. 

B. Primary Children: The comparative size of two 

or three objects, such as books or pencils, or the 
comparative size of other children may be ques- 
tions asked. 



Backward Children. 21 



Test of Number: — 

A. Kindergarten Children: The perception of num- 

ber may be tested by asking the child to count 
the number of pennies on a table or the marks 
on the blackboard. The concept of number may 
be tested by simple abstract processes, such as 
adding two and three, and multiplying small 
figures. 

B. Primary Children : Test as for A, but with larger 

numbers. 
Lack of number percept indicates very low mentality. 

Test of Perception of Weight : — 

A. This may be omitted with kindergarteners. 

B. Primary Children : Test by using large pill-boxes 

of the same size, but filled with substances of 
different weight. Let the child take a box on 
the palm of each hand and discover the heavier. 
Any two objects of about the same size, but of 
different weight, will answer. 

Test of Perception of Temperature: — 

A. Kindergarten Children: This test may be omitted. 

Children with lack of temperature sense are the 
victims of serious organic nervous disease, and 
therefore not encountered in public schools. An 
endeavor to test the ability to perceive compara- 
tive temperatures in very small children is diffi- 
cult and apt to be terrifying to them. 

B. Primary Children : Take two tumblers of water, 

one warm and the other cool, and have the child 
distinguish temperature by dipping the fingers 



22 The Medical Examination of School. Children. 

of the same hand into them. This test need only 
be apphed to extreme cases of backwardness, 
where imbecihty or idiocy is suspected. 

Test of Memory: — 

A. Kindergarten Children: See if the child remem- 

bers his name, age, number of brothers and sis- 
ters, and the names of familiar animals and ob- 
jects. 

B. Primary Children: Also the child's address, the 

names of other boys, other streets, father's name 
and business, events of the da)'-, etc. Reading of 
words is a test of the memory, requiring also a 
normal perception of form in order to first dis- 
tinguish the letters. 

Test of Attention : — 

This is really a matter of observation as much as 
test, but a test has the advantage of accuracy from 
being conducted systematically. The children should 
be told a story or shown a series of colored pictures 
or unusual articles. The story told should not be too 
interesting or too dry. Those with poor powers of 
attention soon betray it by their wandering eyes and 
vacant facial expression. 

Test of Coordination : — 

A. Kindergarten Children : Inability to button clothes, 

and to do the ordinary kindergarten exercises 
with blocks, pegs, and paper strips. 

B. Primary Children: Inability to thread large-eyed 

needles. Inability to do the simpler physical 
exercises, such as touching the fingers over the 



Backward Children. 



23 



head. A precision test may possibly be useful. 
It is given in the Appendix. 

Test of Associations: — 

The association of ideas may be tested by en- 
deavoring to elicit from the child prominent charac- 
teristics of a thing mentioned, or opposite qualities and 
characteristics may be sought for. The request may 
be made to name the whole after the exhibition of a 
part. These may be done informally with each indi- 
vidual child, or a class test may be made by giving 
to each pupil a printed list, with a request to set down 
alongside of each term given its opposite adjective. 
Such a test, already standardized by Dr. Norsworthy, 
by experiment on several hundred children, is as fol- 
lows : — 



List A given. Pupils (boys or girls) 
asked to write list B ; 20 words maximum ; 
no time limit. 



List B 



Number of Oppo- 
site Character- 
■*^86 istics Correctly 

Sttaed 



9 

12 
15 

16^ 



9 
13.5 
15 

15.5 



Normal Limit 
of Variation 

2 

2.6 
2.3 
2.3 



List B given. Pupils (boys or girls) 
asked to write list A ; 20 words maximum ; 
no time limit. 



Normal Limit 
of Variation 





Number of Oppo- 




siie Character- 


Age 


istics Correctly 




Stated 


9 


9.5 


12 


14.7 


15 


18.5 


\Q\ 


19 



1.7 
3.6 
2 
2 



good 
outside 


bad 
inside 


quick 
tall 


slow 
short 


big 
loud 


little 
soft 


white 


black 


light 

happy 

false 


dark 

sad 

true 


like 


dislike 


rich 
sick 


poor 
well 


glad 
thin 


sorry 
thick 


empty 


full 


war 

many 

above 


peace 

few 

below 


friend 


enemy 



Test of Imitative Faculty: — 

This is best shown in physical exercises. Test by 
facing the class and asking them to imitate the move- 



24 The Medical Examination of School Children. 



ments. After the coarser and easier movements have 
been tried, Dr. Francis Warner suggests a finger ex- 
ercise, such as bending certain fingers simuhaneously, 
and moving one finger from side to side. This idea 
was first suggested by Seguin ("Idiocy and Its Treat- 
ment"). 

Test of Reason : — 

Reason is in reahty a complex act, involving so 
many mental factors that it may be safely taken as an 
index to the intellect itself. The good judgment or 
reasoning power of the individual is therefore the best 
criterion of his intellect, and Professor Johnstone, of 
the New Jersey Backward School, has said that to him 
the foremost characteristic of feeble-minded children 
is the lack of good judgment displayed by them in 
their ordinary activities. 

Some tests of reasoning power are simple enough 
in themselves, and yet they should be made carefully, 
since a timid, confused child will not do himself jus- 
tice. His confidence should be secured by dealing 
with him in a gentle, deliberate manner, and by ask- 
ing him a few easy questions of no particular conse- 
quence. 

Such questions as these will test the reasoning 
power : — 

"What would happen if I put my finger in the 

fire?" 

"What would happen if I went out in the rain?" 

"What will the dog do if I kick him ?" 

"Why does the man carry an umbrella?" 

"Why do you wear an overcoat to-day?" 

Or (exhibiting a picture of a girl and a broken 

doll), "Why does the little girl cry?" 




High-grade feeble-minded girl. 
Institution case. 



Backward Children. 25 



The general way in which this information is 
given to the examiner is the best single index of the 
child's mental capacity. I remember one occasion 
(not in the public schools) on which a normal child 
who had been mistakenly sent by a nurse with several 
feeble-minded children to be examined and committed 
to an asylum, showed at once, by his prompt, clear 
answers, his healthy mind. 

Illustrative Case: — 

A fair example of what may be ascertained by any 
intelligent teacher, after reading these instructions as to 
observation and test, is as folows : — 

C McC ; age, six years ; good family. Has 

been in the first grade two months and is so stupid that 
he does not know a word or a letter, and cannot add two 
and two. It is difficult to get him to talk. His speech is 
fair but short, much like that of a quiet three-year-old child. 
He seems to have no memory, although he imitates well 
enough. His attention is always wandering, and he ap- 
pears restless. Frequently he stands up in his place, turns 
and leans over the desk behind him, with no apparent reason 
for so doing. He occasionally pinches the other boys around 
him. He appears to see well enough, but breathes through 
his mouth. He has a good color and complexion, and is a 
rather good-looking boy, although his face has very little 
expression. 

By test he told his name but not his address, saying 
that he lived "down there," pointing in any direction. (He 
knew his way home every day, however. ) He did not know 
his parents' names, and, on being pressed to name a brother 
or sister, gave the name of a classmate. On being asked 
his teacher's name (he had had three, owing to the sickness 



26 



The Medical Examination of School Children. 



of first one and then another), he gave the name of his first 
teacher, last seen two months since. He had little or no 
perception of color, form, number, or weight, calling a red 
vase and a green blotter "blue" not recognizing letters, 
stating that two fingers plus two more fingers were "five." 

Obsorvatioiis on CMId 

Proposed for an Uegraded Class 



RS.. 



Name 




X 



Borough 



...7../-L. 



/- 



Age. 



Home con£!&oia..^U4k^:'}J6.r-.i::/SAS^. 



Habits 



...fi. ..i^fe5tf,....j»^£2fe<d»:<-. Grade Za, 

Nalkfflsdi«y.^&J^*«^!2*<<;,/^^ 

School atteiBdamce-.uxe<2*iC!«jM,<iia^:^...«2r...^^ s^OrfetjC^^fe^fewSfe^^ 

Cause of any irreguSarity-— -«<;^^:i2i^^**^?*^- -'^--.^ 

Health....- x/^<^^-.^ -l£^^tct^-..j:3!L.a&i^^Ude2i^.'. „.. 

Peculiarities ...dqfJAJU3MJi-..4GAJ^^ ^.. /»c<^. .mi<<^i^^. 

Observation™ .0?a:>5^: — „ Attentk>iis2^^<;<J^2<Jt&«.Memory.w4c^^ 

Oral >^r^]x>n^^§f^iU,>J^J.M^<R^ 

Special tastcs.i^?to<«<X^c....(W^a£2S^d£i^^ 
Any othw \isS9ra&^afsa--.X^UJ!,^t<.i^i'U0Lt., 



, ^ /) Ij I 

%J..,fd^JiJLi!^....-:^ „ 





Date. 



M!C&i:£^kPC^&>£.^... 



.190 



•/• 



PrincipaL 



Backward Children. 27 



He recognized a penknife and a pencil, however, called a 
five-cent piece a ''quarter," and knew that the dog was 
bigger than the cat. He was reminded that "the doggie 
barked," and was then asked what the cat did. The cat 
"jumped over the fence," which was a bright enough an- 
swer, although a failure in the endeavor to test his asso- 
ciation sense. A preliminary diagnosis of backwardness 
was made, the stupidity probably caused by adenoid growths 
in the pharynx. 

Systematic observation and test by the teacher having 
been made, these should be recorded. A printed blank for 
this purpose is very helpful to the teacher without special 
knowledge or previous experience. An actual case history 
on the form provided by New York City is here given. 

B. Medical Examiner's Official Diagnosis of Backwardness. 

The medical inspector or consulting psychiatrist should 
confirm or reject the teacher's preliminary diagnosis by: — 

1. A Review of the Teacher's Record. 

2. A Careful History of the Case. 

3. A Thorough Physical and Mental Examination. 

1. Review of Teacher's Record: — 

The tests and points of observation should be 
repeated, the object being the confirmation of the pre- 
liminary diagnosis. If it be the first case passed upon 
by the teacher in her teaching career, the skill and ex- 
perience of the physician may lead to an opposite con- 
clusion. An- experienced teacher is, however, usually 
correct in her judgment. 

The official diagnosis of backwardness is largely 
a matter of expediency. Pronounced cases should be 
removed at once from the general class, as a relief to 



28 The Medical Examination of School Children. 

their fellows, the teacher, and themselves. Less evi- 
dent cases should be classed as backward only when the 
facilities for dealing with these children are satisfac- 
tory. 

In an ideal school system, with special classes con- 
ducted unostentatiously in the regular school buildings, 
the teacher's diagnosis should be accepted. This in- 
cludes all doubtful cases with no confirmation of the 
mental defect from either the history or the physical 
examination. In the ideal special school the children 
are given individual instruction under skilled observa- 
tion. The environmental conditions rendering an ex- 
act diagnosis possible are obtained, and the public is 
none the wiser. On the other hand, in cities with no 
special provision for backward children, or in those 
where a poorly organized system herds the incorrigi- 
bles and plain backward children together, or com- 
pels the backward children to travel long distances to 
special centres, the diagnosis should be made with cau- 
tion. Under these conditions the backward child is 
treated with scant consideration and publicly stigma- 
tized. Therefore, parents have a right to demand that 
mental defects in their children shall be certified to by 
a physician from personal observation and examina- 
tion. 

2. The History of the Case: — 

This comprises (a) the family history, which may 
show a record of insanity, idiocy, intemperance in the 
parents, {h) The personal medical history, such as 
injury at birth, subsequent accidents, or disease, such 
as meningitis. (c) The social histor)^ particularly 
the factors of poverty and neglect, and intemperance. 



Backward Children. 29 



Since intemperance is the most potent of all 
agencies in producing degeneracy, its existence in the 
child's parents should always be suspected and inquired 
for. In this connection I may quote from an admirable 
paper by Dr. T. Alexander MacNicholl/ of New York 
City:— 

"Beer-drinking children are notoriously sluggish 
in their mental operations, while spirit-drinkers gravi- 
tate into habits which seriously impair the higher in- 
tellectual properties and cloud the judgment. 

"When the drink habit is linked with an heredi- 
tary alcoholic taint, dullness is perceptibly increased. 
From 15 to 25 per cent, of drinkers, free from heredi- 
tary alcoholic taint, are dullards. From 53 per cent, 
to yy per cent, of the descendants of a drinking an- 
cestry are dullards. From 4 per cent, to 10 per cent, 
of the descendants of a total abstinence ancestry are 
dullards. 

"drinking habits of children. 

"Dividing the pupils into two classes {a) pros- 
perous; (6) poor, we have the following: — 

"(a) In this class, 32 per cent, have drinking 
parents; 68 per cent, have abstaining parents, {h) 
In this class, 85 per cent, have drinking parents; 15 
per cent, have abstaining parents. {a) Of 12,919 
dullards, 9,689 had drinking parents, {h) Of 3195 
dullards, 2715 had drinking parents. 

"One hundred and two children in twenty-five 
families of heavy drinking parents show the follow- 
ing: Seven had tuberculosis, 8 had diseases of the 
heart, 31 had functional diseases of the nervous sys- 



'^ "Alcohol and the Disabilities of School Children," Journal of the 
American Medical Association, February 2, 1907. 



30 The Medical Examination of School Children. 

tern, 41 were drinkers, 6 were degenerates, and 4 were 
idiots. Only 5 of the entire number were normal. 

"Tracing ten families of total abstaining parents, 
we note the following: First generation, 34 children, 
of whom II per cent, suffered from organic or func- 
tional diseases; second generation, 38 children, of 
whom 26 per cent, suffered from organic and func- 
tional diseases ; third generation, 58 children, of whom 
7 per cent, suffered from organic and functional dis- 
eases. 

"Ten families of moderate-drinking parents show 
the following : First generation, 47 children, of whom 
59 per cent, suffered from organic and functional dis- 
eases; second generation, 90 children, of whom 62 per 
cent, suffered from organic and functional diseases; 
third generation, 82 children, of whom 95 per cent, 
suffered from organic or functional diseases." 

3. Physical and Mental Examination of Backward Chil- 
dren : — 

Briefly, the following characteristics are notice- 
able in this connection. They may or may 
not be present: — 
' I. Defects of the special senses in greater proportion 
than is found in average children. 

2. Certain special physical markings (a) indicative of 

injury to the brain {e.g., depressions on the skull, 
paralyses), or {h) indicative of possible degen- 
eracy {e.g., asymmetrical ears or skull, faulty de- 
velopment of anatomical organs or members). 

3. Words and actions of a crude or purposeless or 

immoral character {e.g., grinning, uttering of 
uncouth sounds, and the commission of crime). 



Backward Children. 31 



4. Poor nutrition. 

5. Nervous disorders. 

By these various means the medical inspector should 
arrive at a fairly exact diagnosis of the grade of the mental 
defect and the cause of the mental defect. 

He should make his classification as scientific and ex- 
act as possible, giving consideration to the age of the 
person examined, the grade of intelligence existing, and 
whether it is improvable or not. For this purpose it is most 
convenient to state primarily whether the patient be a child, 
youth, or adult, and by qualifying adjectives to further 
state whether he is progressing, stationary, or retrogress- 
ing, and the grade of mental defect at the time. Thus the 
diagnosis may be "male, improvable imbecile child," "male, 
retrogressive idiotic youth," etc. The cause of the defect 
may be "alcoholism," "syphilis," "injury at birth," "deaf- 
ness," "hydrocephalus," etc. 

Eecord of Case. 

It is obviously important that systematic record be 
made of these cases while in the special classes. For this 
purpose a large individual record-card should be kept, con- 
taining full information contributed both by the teacher of 
the class, and by the medical examiner. Such a card is here 
presented. On the reverse side is a list of detailed points 
to be considered in every case. Furthermore, a child trans- 
ferred to a special class should have sent with it all the 
helpful information possible ; and a blank space is reserved 
on the reverse side of the card for such notes received. To 
facilitate this, blank cards should be kept on hand in every 
school. A child re-transferred to a regular grade should 
take a duplicate of his special record-card with him. 



^ to 



Ow H Q 



z 
o 

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12: <j o fa 



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— eS cS <» o W ^— 
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No. Name 








Grade Class 




ISO Address 




Grade Class 




190 . Address 




School 




190 Teacher 




School 




190 Teacher 




Progress EOF 


D vD Date of birth 


Age 


Conduct B G P 


D vD Age on entering school 


No. years in school 


Attendance vR R I 


vi 


A School history (Rel) 




Most deficient in 








Best in 








Habits 












5 4 3 2 1 


5 4 3 2 1 


Father living dead 
Mother living dead 
Step-father, Step-mother 
Nationality F. 


Normal vG G M SI D 


Deficient BkwIHIM U id 


Health vG G P P vP 


Home Care vG G F P vP 


Nutrition F G M P St 


" Culture vG G F P vP 


Support R W M P vP 


" Discipline vG G F P vP 



Trunk 



M 
Birthplace 
Lives with 
Home Lang. 
Older brothers living dead Arms 

" sisters 

Younger brothers " 

" sisters " 

Eye. R. ' } 



Occupation of provider 



Child works at 



Anormality 



Asymmetry 



Legs 



Hands 



Feet 



Cranium 



Forehead 



Face 



Ears 



Eyes 



J 



Nose 



Lips 



Eye, L. 
Defects 
Disease 
Ear, R. 
Ear. L. 
Defects 

Disease 

Co-ordination 5 4 3 2 1 Tonsils 
vB Bold Norm Shy vS Naso-ph'nx 
Am Resp Pass Bull Sur Mth Breathg 

Slo In Al Nerv vN Teeth 

vR Refl Norm Imp vl Tongue 



Palate 



Stu Wilf Firm Flex Vac Voice 
Stammer (inf) 5 4 3 2 1 Speech 
Stutter 6 4 3 2 1 Diseases 
Filled in by D3*« 



Laboratory of Psychology. University of Pennsylvanii 
The J. Lewis Crozer Fund. 



Record Card used in Psychology Classes of Dr. Lightner J. Wkmer, 
University of Pennsylvania. 



36 The Medical Examination of School Children. 



IV. THE INSTRUCTION OF BACKWARD CHILDREN. 

Function of Special Classes. 

The special classes for backward children, maintained 
as a part of the public-school system, have two principal 
functions. First, they act as laboratories for exact study 
and diagnosis, and subsequently as clearing houses for the 
ultimate proper disposition of the pupils. Second, the chil- 
dren receive assistance for physical and mental defects ac- 
cording to their individual necessities. 

These classes should be maintained strictly for the 
education of backward children, in order to render effective 
the energy and labor of their instructors. Therefore, all 
children sent to such classes should be classified as primarily 
backward or primarily incorrigible, depending on whether 
the intellect or the moral sense is lacking. For these two 
dissimilar groups the best results are obtained by sepa- 
rate instruction, since in the same class-room they are not 
only retarded, but they react badly upon each other. 

A second step is the separation of those of the back- 
ward children who are actually feeble-minded and the plac- 
ing of them in the institutions designed for such perpetually 
helpless cases. 

In the class for simply backward children, the final 
step is the division of the suitable pupils into two sub- 
groups, the truly backward, with inherent brain defect, and 
the pseudo-backward, made dull by curable physical defects. 
This, I believe, is the plan adopted in New York City, It 
may be expressed schematically thus : — 




High-grade feeble-minded girls. 
Institution cases. 



Backzvard Children. 37 



Backward children 



Types of Pupils Admitted to Special Public School Classes. 

Pseudo-backward (simply sensory 

defects). 
Truly backward. 

Feeble-minded. (To be sent to 

some suitable institution as soon 

as possible.) 

Children either intellectually bright or intellectually 

backward, but primarily vicious, incorrigible, truant, 

or petty criminal. 



The advantage, or rather necessity, of convenience, 
accessibility, and privacy in the location of the classes has 
been already mentioned. 

Personality of the Teacher. 

The teacher's personality is the second factor for suc- 
cess in this work. Like the regular-grade teachers in the 
slum districts, they should be better paid, because of the 
difficulties they encounter. Because of the diseased and 
defective minds they are called upon to reach and inspire, 
their qualifications should be exceptional. In this connec- 
tion, Dr. Fernald has admirably expressed his views in a 
recent address before the Public Education Association of 
Philadelphia : — 

"The general supervisor having immediate charge of 
these special classes "should have no other duties. She 
should be thoroughly familiar with the recognition and 
education of backward children. Her field of work should 
be sharply defined and limited, in order to get the proper 
perspective. 

"She should have all the natural qualifications de- 
scribed above, plus successful experience in teaching back- 



38 The Medical Examination of School Children. 



ward children, plus executive ability. She should super- 
vise the selection and training of the teachers, the plan of 
work, and the details of the highly specialized school exer- 
cises. 

Further, in regard to the qualifications of the teacher 

of the special class for backward children : — 

"Teachers should be selected with sole regard to their 
fitness for this difficult work. They should begin the work 
young, as a rule. They should have robust physical health, 
a hopeful temperament, great patience, tact, and originality. 
They must be fond of children, sympathetic and kind, but 
firm and decisive. The personality of the teacher is the 
all-important factor. 

"A teacher with the above natural qualifications, with 
kindergarten or normal training, and a little experience in 
primary work, would be well equipped. Normal training 
in gymnastic work and the manual occupations would be 
very helpful. . . . No merely routine teacher can suc- 
ceed in this work." 

"Each class-room should have a liberal supply of ap- 
propriate kindergarten and school material, many attractive 
models, and apparatus for object-teaching, apparatus for 
manual training and special sense training, pictures and pic- 
ture books, and a piano." 

Personally, I am glad to testify to the intelligence and 
enthusiasm of the New York teachers engaged in this work. 
I have met about twenty of these young women, and, with- 
out exception, they were intensely interested in the prob- 
lems of their special profession. Many of them possess 
cameras, and keep private case-books, illustrating the rec- 
ords with photographs of their cases. The real credit, how- 
ever, is due to the educational authorities of the city of New 
York, who furnish them pleasant summer-school instruc- 




High-grade feeble-minded boys, 
institution cases. 



Backward Children. 39 



tion and inspiration in training schools for feeble-minded 
children, and also free winter lectures on subjects pertain- 
ing to their work. The time necessary to take up this extra 
work is wisely credited to the teachers who avail themselves 
of it. 

Methods of Training Backward Children. 

These should be medical, physical, and educational in 
character. 

First of all, the general health of the backward child 
should be carefully supervised. A prize animal receives 
more attention than does the average child in this respect; 
and a backward child of the lower social class is usually 
totally neglected by its ignorant parents. Good food, fresh 
air, proper sleep, and possibly medical attention are neces- 
sary. A healthy circulation nourishes brain and body alike, 
but, in addition, each of the latter is itself a stimulating 
vital factor. The general health and that of the mind are 
interdependent. The vigor or stagnation of one is closely 
reflected in the other. 

Eye-glasses should be provided, enlarged tonsils and 
adenoid growths removed, decayed teeth filled or extracted, 
and chronic suppurations, such as discharging ears, given 
surgical attention. Nasal obstruction from adenoid masses 
in the nasopharynx very often produces a remarkable con- 
dition of poor health and mental dullness, due to the re- 
sultant catarrh, dyspepsia, poor respiratory action, narrow, 
high palate and irregular teeth, and catarrhal deafness. 
Their removal causes a corresponding general improvement, 
although round shoulders, flat chest, and a characteristic 
facial expression frequently remain as permanent deformi- 
ties. Examples of the latter are seen in the picture show- 
ing the group of New York children returned from the 



40 The Medical Examination of School Children. 

country {q. v.). It is unnecessary to say to any thinking 
person that the removal of adenoids existing in a child 
with inherent mental weakness will not give the child a 
new brain. In these cases the existence of the nasal ob- 
struction is a coincidence, not a cause. 

The second desideratum should be the correction of 
any existing sensory defects (poor eye-sight has been al- 
ready mentioned), in order to improve the perceptive fac- 
ulties, and the exercise of these same faculties by games 
and tasks requiring the use of sight, hearing, and touch. 

The third step is practically simultaneous with the sec- 
ond. It consists in the development of the motor nerves 
and the will-power by active games, simple exercises, calis- 
thenic drills, and manual-training work. 

By the progressive exercise of the primary sensory and 
motor faculties, the higher ones of attention, memory, rea- 
son, and coordination are at the same time brought into 
play and developed. 

With the improvement of the intellect is seen a recipro- 
cal improvement in the body health. The alert mind shows 
itself by quickness and precision in muscular movements; 
while in those children of the nervous and irritable type, 
better self-control is attained by the building up of the nerv- 
ous system and a corresponding reduction in the irritability. 
An improved nerve-tone shows itself also by a firm, steady 
gait and erect carriage, and a general brightening up, due to 
the use and development of the muscles of facial expression. 

The school work proper should be conducted in such 
a way as to combine the acquirement of knowledge with 
the constant exercise of the physical senses. The objective 
method of teaching is the proper one, and indeed is the 
only successful one. It is by the constant recourse to attrac- 
tive and bright-colored, concrete illustrations that the teach- 



Backzvard Children. 41 



ing of the elementary branches in these special classes differs 
from that of the ordinary primary-school curriculum. The 
limit of the capability of truly backward children is about 
equal to the end of the fourth year of the regular school 
course. Knowledge is naturally acquired slowly and usually 
retained with some difficulty, by reason of poor memory. 
Both for their intrinsic educative value, and for their pur- 
pose of fitting the scholars for a useful place in the world, 
industrial and mechanical occupations gradually supersede 
the simpler exercises designed purely for manual training. 

An interesting article from actual observation, on the 
conduct of the special school classes of New York City, is 
given in the New York Medical Journal (September 7, 
1907), by Dr. C. E. Atwood. It serves to illustrate the 
principles already emphasized. 

Concerning one of the schools for simply backward 
children, Dr. Atwood writes : — 

"One of the best-conducted of the ungraded classes 
which I visited was in Public School No. 18, on East Fifty- 
first Street. This was presided over by a teacher who has 
had the advantage of training in an excellent private school 
for the feeble-minded. The children are of the lowest 
grade. The day's programme, arranged by this teacher, 
subject to great variation, is somewhat as follows: From 
9 to 11.45 A.M., and from i to 3 p.m., with appropriate 
intermissions, the children pursue various tasks calculated 
to train the senses and to develop them on the motor side. 
They dust and arrange the room ; name objects in picture 
books, and learn about their attributes ; sing songs ; listen 
to a story concerning which they may make observations ; 
study Nature by means of a little garden, where potatoes, 
peas, lettuce, onions, etc., are planted by the pupils them- 
selves in a rough box ; carve simple shapes in wood ; select 



42 The Medical Examination of School Children. 

and match colors; have simple gymnastics; test their 
smelling and tasting; pursue various games under instruc- 
tion to aid in self-control and improve in precision of hand, 
eye, and ear; then there are exercises in drawing on the 
blackboard, counting with money, brush work with colors, 
modeling in clay, word pictures, Indian club and dumb-bell 
exercises, etc., the whole concluding with dancing and 
marching with piano accompaniment, special attention being 
given to the attitude, rhythmic body movements, and man- 
nerly deportment. 

"The ungraded classes of all the schools make occa- 
sional visits to museums, the aquarium, and zoological 
garden for objective teaching; and to Forest Hills and 
Bronx Park for field work. Materials from some of the 
museums are also loaned, so that the objects themselves may 
be seen and studied." 

Another school designed for the vicious truant and in- 
corrigible class was also visited. It will be noticed from 
the context that the majority of these children are mentally 
defective as well as depraved. 

"Public School No. 120, on Broome Street, is a school 
entirely for incorrigible boys. Many are on parole from 
the courts in care of the principal, and others are sent by 
principals of other schools as incorrigibles, who would oth- 
erwise be either suspended or sent to the Truant School. 
They are incorrigible on account of either faulty home con- 
ditions or defective mentality. In the first class visited 
there were fifteen ; one boy seen had two brothers who are 
professional thieves; one was defective and degenerate, 
sixteen years old, with mentality of six. They were mostly 
street boys with, as the principal expressed it, a superficial, 
brightness. In this class the teacher selects some subject 
which becomes a centre of interest. At the time of my 




High-grade feeble-minded boys. 
Institution cases. 



Backward Children. 43 



visit the subject was "The Farm," and everything that 
could be drawn on the board, thought of, made, etc., per- 
taining to a farm, was brought up for discussion and treat- 
ment, and at once awakened marked interest. Several were 
cutting out birds from paper ; one was weaving a basket in 
the shape of a bird's nest. Another had three baskets al- 
ready made, etc. There is a gymnasium and also a bath 
in this school, as in the regular public schools. In one class 
two boys were working in leather. In the shop the lowest- 
grade boys were doirtg wood-carving and carpentry. 

"There are nine classes in the school. Most of the 
pupils have no sense of right and wrong at the start. One, 
e.g., before coming, had been learning to steal for a living, 
and thought it no harm. Ages run from ten to fifteen years. 
Punishment is only by deprivation. Pupils have to earn 
their privilege by good behavior. The boys are of suitable 
age for the grammar grades, but are only able to do the 
lowest primary work. Some learn to count by simple meth- 
ods. Others put sentences together with separate printed 
words, each pupil being given a picture as topic. 

"The school has been open two years. There are 135 
pupils, drawn mostly from two school-districts of the down- 
town East Side, representing ten schools, each of at least 
2000 pupils. Ten or eleven parochial schools send a few, 
and some boys are picked off the streets. A great many 
of these incorrigible boys are here fitted for remunerative 
employment outside. Fifty-one out of a total of about 350 
(or one-seventh) have been sent out; all but six have been 
heard from and are doing well at unskilled labor, e.g., as 
messenger boys, telegraph boys, and various employments 
in department stores and down-town business places." 

Personally, I have had but one opportunity to inspect 
the New York City special classes. The school visited is 



44 The Medical Examination of School Children. 

located at i6o Christie Street, in the East Side slums dis- 
trict. The poverty and overcrowding of tenement life here 
furnish striking specimens of degraded youthful humanity, 
many of whom should be in institutions rather than at 
large on the streets. The class consisted of twenty children, 
of whom the majority were actually feeble-minded, rather 
than backward as the term is ordinarily used. Two or three 
were high-grade imbeciles. Squinting eyes, slouching fig- 
ures, malformed skulls, limping gaits, and defective speech 
were everywhere manifest. A remarkable shyness, due, I 
suppose, to lack of will-power and of self-confidence, was 
manifested in several. These latter children obstinately 
hung their heads when talked to, although evidently quite 
fond of their teacher. Several were very interesting, as, 
for instance, a case each of cretinism, of hydrocephalus, 
and of echolalia. A wide, shallow sand-box, possibly six 
feet long, gave unceasing interest to one of the lower-grade 
children, whose attention it was impossible to obtain by 
other devices. 

The general grade of intellect and school progress was 
very low; but notwithstanding this disheartening human 
material, the class teacher, Miss Leech, had all interested 
and busy at some light manual work, training the attention 
and the muscular coordination. In the hall a large book- 
case full of raffia and sewing work bore testimony to the 
skill attained in these occupations. An illustration shows 
some of these actual specimens. 

Improvement under such skilled instruction is usually 
in sharp contrast to the previous condition of apathy, sullen 
defiance, or pitiful despair. A visit to these classes im- 
presses one first of all with the atmosphere of cheerfulness, 
optimism, and progress which exists. 

Unfortunately, some of the children respond but little, 




i V<iAi>iHi 




Specimens of basket and mat work done by pupils of one of the 

New York special classes for backward children. 

(Loaned by Miss M. H. Leech.) 



Backward Children. 45 



a lesser number do not improve at all, and in very rare in- 
stances mental deterioration may be proceeding in spite of 
all efforts. 

These discouraging cases with the intellectual limit 
apparent should not distract our attention from the evidence 
of great improvement in the majority. The classes are es- 
tablished for the backward rather than the feeble-minded 
and imbecile, and the latter, at least, should be weeded out 
at once when detected by their failure to progress, and sent 
to proper institutions. 

Evidence of improvement is shown by speech, facial 
expression, and actions. The motor side, therefore, is the 
index of progress. The better articulation and use of 
words, the better ability to play the games, follow the drills, 
and perform tasks requiring coordination, are infallible 
signs of improvement in those cases where the regular 
school studies have been so recently begun that improve- 
ment is uncertain. 

Mental and Physical Equilibrium to be Sought and 
Maintained. 

Individual instruction and the fitting of the studies to 
the child's necessities are also most important from the 
standpoint of the child's future health. 

Exercise should be along the broadest lines, and every 
part of the body and of the nervous system should be called 
upon for action. A healthy circulation and equilibrium are 
thus maintained, or at least striven for. It is a well-known 
physiological fact that persistent exercise of one part, with 
neglect of another, results in actual decrease in vitality of 
the latter by distraction of the circulation from it. 

Recognizing the lack of spontaneous action in these 
children, and the defect resulting from disuse, a constant 




\\\ 

46 The Medical Examination of School C. 020 730 576 5 ( 

endeavor should be made to exercise and develop each part 
in turn, and to subsequently prevent degeneration from the 
same negative causes. 

On the other hand, while increased stimulation of any 
part increases its power of response to the stimulus, if per- 
sisted in too far a diseased condition of irritability may re- 
sult. This is particularly true in the neurotic, with their 
functionally weak and unstable nerve centres; in the epi- 
leptic, where some focus indicative of previous accident or 
brain disease often already exists ; or in those children who 
have had meningitis or other inflammatory brain diseases. 
In these cases over-excitation may cause nervous explosions, 
resulting in epileptic convulsions, hysterical attacks, or other 
emotional outbreaks. In cases of feeble mind or of moral 
imbecility deserving of institution custody, an outbreak of 
insanity or the sudden commission of crime may result. 
The first consideration in the care of these children is free- 
dom from nervous strain, the scholastic education of the 
child being unhesitatingly sacrificed wherever necessary. 
Short school hours and country life among congenial sur- 
roundings constitute the ideal environment. 

If this same wise balance between neglect and over- 
stimulation had been sought after by the parents of these 
unfortunate children, the majority of the latter would not 
exist as mute testimony to the violation of Nature's laws. 

The disposition of the truly backward children, espe- 
cially of the low-grade cases among the poor, is a most im- 
portant subject, which is, however, outside the province of 
this paper. Most of them possess such mixed powers and 
weaknesses that the)'- are capable of self-support if given 
home or institution supervision, but prone, if neglected, to 
sink to the lowest depths of physical, moral, and mental 
depravity. 



LIBRARY OF CONGRESS 



020 730 576 5 



